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Books: ‘THE CHECKLIST MANIFESTO,’ by Atul Gawande

I have been a fan of Atul Gawande's work since first reading his books Better and Complications. I was also captivated by his 2009 New Yorker article on the high cost of care in McAllen, Texas (6/1/09) and the insights it provided into the spiraling cost of heath care. I missed The Checklist Manifesto when it first came out, but now that it is in paperback, I had a chance to read it.

Gawande, a MacArthur fellow, first addresses the growing complexity of medicine and the disturbing frequency of complications by distinguishing between errors of ignorance, where we don't know enough, and errors of ineptitude, where we don't use what we already know. He explains how 21st century medicine has produced skilled, well-educated, dedicated, expert physicians who still are overwhelmed by a field of increasing complexity.

Medicine is now more than 13,000 different diseases, syndromes, or types of injury. There are more than 6,000 drugs in common use today, and the typical physician in solo practice will evaluate more than 250 different primary diseases and conditions each year. Specialization and super-specialization reduces the knowledge requirement and data overload but at the cost of fragmentation of care.

Gawande suggests that in a time of staggering complexity, checklists may be at least a partial answer to the complexity dilemma and the shockingly high complication rates seen in medicine today. He explores the origin of checklists in fields far removed from medicine. For example, airline safety and flight checklists have made airline fatalities very rare. and checklists in complex skyscraper construction have reduced the rate of building failures to 0.00002 percent.

Consulting with experts in these and other fields as he struggled to develop surgical operating room checklists, he discovered that all successful checklists also specify communication tasks as well. The success of checklists may be due as much to the empowerment of the assembled teams as to the specifics on the checklists. The lists stimulate what he calls an “activation phenomenon” that gives team members a sense of participation and responsibility and a willingness to speak up.

Bad checklists, he learned, are vague, imprecise, too long, hard to use, and impractical. Good checklists are precise, efficient, easy to use, and provide only reminders. They are not “comprehensive how-to guides, but quick simple tools aimed to buttress the skills of expert professionals.”

Certainly in the operating room checklists appear to work remarkably well. In an international study of a WHO Safe Surgical Checklist evaluated in eight hospitals across a wide spectrum of hospital conditions, Gawande's team used a 19-step checklist applied within two minutes to successfully reduce major complication rates by 36 percent and fatality rates by 47 percent. This study published in 2009 in the New England Journal of Medicine (2009;360:491-499) has been reproduced in large part in multiple other institutions since then. Imagine if such reductions resulted from a new wonder drug or medical device. We would all herald it as a dramatic advance.

Some critics have argued that such checklists are applicable only in the more structured setting of the surgical suite. Gawande suggests that similar tools could be developed for a wide variety of medical problems including heart attacks, strokes, drug overdoses, and seizures. Indeed, many hospitals have employed such checklists with success. Why then, the resistance to something so simple that seems to save lives?

Gawande believes that medicine resists it because “it pushes against the traditional culture of medicine with its central belief in expert audacity—the right stuff.” Checklists in their simplistic approach seem to fly in the face of a learned physician's expertise. Not so, says Gawande. Checklists reward expertise and allow for team participation in complex decision-making. All areas where checklists have been applied with success emphasize the parallel benefits of team empowerment.

Gawande is a gifted writer and storyteller. His firsthand conversations with airline pilots, construction engineers, and investment experts are conveyed with clarity and style.

The book is most persuasive when focused on medicine. The case for checklist utility in government, finance, and other walks of life would be more convincing with a more detailed exploration of these subjects using experimental evidence. That is not Gawande's expertise, and the case for generalizing the use of checklists is less well made. One example in the book, the success of Wal-Mart during the Hurricane Katrina crisis, seems a better illustration of individual empowerment and freedom for individual decision-making than it does for the benefits of checklists. Indeed, government delay resulting from established procedures seems to have been an obstacle to success in that chaotic situation.

In spite of our resistance to checklists, in the settings where they have been used in medicine, the data are compelling. Gawande has continued to drill down into further applications in a very recent January 2013 New England Journal of Medicine article—“Simulation-Based Trial of Surgical-Crisis Checklists (NEJM 2013;368:3:246-253). Seventeen operating room teams participated in 106 simulated surgical crisis scenarios. Six percent of critical steps were missed when checklists were used versus 23 percent when they were unavailable (p<0.001).

With 150,000 worldwide deaths post-surgery, almost half preventable, we would all be wise not to dismiss the simple checklist approach just because it seems too easy to be true.

Nonetheless such checklists at best can be expected only to reduce and not eliminate human error. For this we will ultimately need failsafe systems where human decisions are not involved. Donald Berwick, former CMS Administrator and past President and CEO of the Institute for Healthcare Improvement, has written extensively about identifying such systems. His examples include cars that start only in park, which eliminates the possibility of driving your car through the garage door even if you forget. Or the simple door closures on airplane bathrooms, which simultaneously lock the door and notify others that it's occupied even if we forget. Perhaps these two creative Boston physicians can collaborate to take reducing risk to the next level.

The Checklist Manifesto is skillfully written, insightful, and challenges convention. It's good reading. Check it out.

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